艾滋病合并新型隐球菌性脑膜炎81例临床特征分析

Clinical characteristics of 81 cases with acquired immunodeficiency syndrome complicated with cryptococcal meningitis

目的探讨艾滋病合并新型隐球菌性脑膜炎(cryptococcal meningitis,CM)患者的临床特征及其转归的影响因素。方法回顾性分析2010年1月至2017年12月首都医科大学附属北京佑安医院感染科收治的81例艾滋病合并CM患者的临床特征、实验室检查、治疗情况和临床转归的影响因素。统计学分析采用t检验、秩和检验和χ^2检验。结果81例艾滋病合并CM患者中,经性传播途径感染71例(87.7%)。最常见的临床症状为发热60例(74.1%),头痛72例(88.9%),恶心、呕吐56例(69.1%)。脑脊液检查结果示:压力升高60例(74.1%),白细胞计数为17.0(6.0,44.5)×10^6/L,单核细胞为9.0(3.0,29.5)×10^6/L,氯化物水平为(117.26±5.61)mmol/L,葡萄糖水平为2.89(2.05,3.41)mmol/L,蛋白质水平为0.32(0.21,0.65)g/L,墨汁染色阳性率为84.0%(68/81),真菌培养阳性率为59.3%(48/81)。血隐球菌抗原阳性率为96.3%(78/81),脑脊液隐球菌抗原阳性率为93.8%(76/81)。不同治疗方案的临床疗效差异无统计学意义(χ^2=1.479,P=0.533)。经治疗好转存活60例,死亡21例,总体病死率为25.9%。单因素分析显示,死亡组患者出现意识障碍病例数和脑脊液压力明显高于存活组(χ^2=22.365,t=0.317,均P<0.05),血清白蛋白水平和CD4+T淋巴细胞计数均明显低于存活组(t=7.975,Z=-3.073,均P<0.05);多因素logistic回归分析结果显示,意识障碍、白蛋白水平是艾滋病合并CM患者临床转归的独立影响因素,其中意识障碍是影响转归的危险因素(OR=26.704,P=0.011,95%CI 2.115~337.247),而白蛋白水平的维持则是转归的保护因素(OR=0.671,P=0.005,95%CI 0.507~0.888)。艾滋病合并CM患者血清白蛋白预测临床转归的受试者操作特征曲线下面积为0.932(95%CI 0.859~0.998,P<0.01)。白蛋白<31.7 g/L时提示临床转归欠佳的灵敏度为95%,特异度为81%。结论艾滋病合并CM病死率高,临床特征缺乏特异性,意识障碍和白蛋白水平是临床转归的独立影响因素。

Objective To investigate the clinical features and prognosis factors of acquired immunodeficiency syndrome(AIDS)patients complicated with cryptococcal meningitis(CM).Methods Retrospective analyses were performed on clinical features,laboratory data,treatment status and related prognosis factors in 81 AIDS patients with CM admitted to the Department of Infectious Diseases,Beijing You′an Hospital,Capital Medical University from January 2010 to December 2017.The t test,rank sum test andχ^2 test were employed to analyze the data.Results Of the 81 AIDS patients with CM,71 cases were infected with human immunodeficiency virus(HIV)by sexual transmission(87.7%).The most common clinical symptoms were fever in 60(74.1%),headache in 72(88.9%),and nausea and vomiting in 56(69.1%).Cerebrospinal fluid(CSF)examination results show that 60 cases(74.1%)had elevated opening pressure,the white blood cell count was 17.0(6.0,44.5)×10^6/L,monocyte count was 9.0(3.0,29.5)×10^6/L,the level of chloride was(117.26±5.61)mmol/L,of glucose was 2.89(2.05,3.41)mmol/L,of protein was 0.32(0.21,0.65)g/L,ink staining positive rate was 84.0%(68/81),fungal culture positive rate was 59.3%(48/81).The positive rate of serum cryptococcal antigen was 96.3%(78/81),and CSF cryptococcal antigen positive rate was 93.8%(76/81).The clinical efficacies were not significant different among different treatment regimens(χ^2=1.479,P=0.533).After treatment,60 patients survived and 21 died,with an overall mortality rate of 25.9%.Univariate analysis showed that consciousness disorder and CSF opening pressure were significantly higher in the death group than those in the survival group(χ^2=22.365,t=0.317,respectively,both P<0.05),while serum albumin(Alb)and CD4+T lymphocyte counts were significantly lower in the death group than those in the survival group(t=7.975,Z=-3.073,respectively,both P<0.05).Multivariate logistic regression analysis showed that consciousness disorder and Alb were independent factors influencing the clinical outcome of AIDS patients with CM.Consciousness disorder was related with poor outcome(odd ratio(OR)=26.704,P=0.011,95%confidence interval(CI)2.115-337.247),and higher Alb was related with good outcome(OR=0.671,P=0.005,95%CI 0.507-0.888).The area under the receiver operating characteristic curve of serum Alb for predicting poor outcomes of AIDS patients with CM was 0.932(95%CI 0.859-0.998,P<0.01).By using 31.7 g/L as cut-off value,the sensitivity was 95%and the specificity was 81%for predicting poor outcome.Conclusions AIDS complicated with CM has a high mortality rate,and its clinical features are lack of specificity.Consciousness disorder and Alb are independent prognosis factors.